STALE DATED WARRANTS.PDF

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: 0 Duplicate or Stale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond to
COUNTY OF MARICOPA numbers on the Instruction sheet which is
page 2 of this form.
PINAL COUNTY MARICOPA JUSTICE COURT PRECINCT #8 (1) being first sworn, upon oath deposes and says:
Name/Claimant
On or about 17-Apr-2013 (date )(2) a warrant/check was issued to the
above named person/entity in the amount as stated below. Such warrant/check was
either never received or was subsequently inadvertently lost or destroyed and there is
no reasonable probability of its being found or presented for payment, or it was not
presented for payment within one year after the date of issuance.
Therefore, under penalty of perjury, claimant hereby affirms that this claim is correct
and the amount shown is due and owing, and the applicant requests that a replacement
.(3)
(4)
Note: Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
(5) Subscribed and sworn to before me this 1/ IA day of ati_ 20 P2/
(45,..ic
NOTARY/PUBLIC LYDIA R. LEGATE
14otnry Public &ale of AniCH18
MAL COUNTY
My commission expires: Wry Commission Expires
June 18, 2015
Ice, 20/5 - (seal)
Warrant/Check Number 330020638
(if known) (6)
Original Date of Issue 17-Apr-2013
(if known) (7)
Reason for original issue of Warrant/Check (8):
El Payroll
0 For Services or Goods furnished
LI Treasurer's refund/payment
Other:

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: Duplicate or 0 Stale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond to
COUNTY OF MARICOPA numbers on the Instruction sheet which is
rage 2 of this form.
1 1405 Tftiel :F(-42-CifV (1), being -first sworn, upon oath deposes and says:
ias r,ngfivIrrftcle. oct_ Gt
t / %Leff t VCC1)
On or about J GI V1 -J- 20It+ (A4t(1". e)(2) a warrant/check was issued to the
above named person/entity in the amount as stated below. Such warrant/check was
either never received or was subsequently inadvertently lost or destroyed and there is
no reasonable probability of its being found or presented for payment, or it was not
presented for payment within one__y_ear_afterlhe_date_ofissuance.
Therefore, under penalty of perjury, claimant hereby affirms that this claim is correct
and the amount shown is due and owing, and the applicant requests that a replacement
warrant/checkbp issued to him/her in the sum of $ 54ID T. 51 .(3)
Sifjned: MDMOS 11tc Er-J-cf-ct4 (4)
Note: Please atterh a copy_xf the warrant/check if available and/or any other
evidence th,ata\warrant/check was originally issued.
d sworn to before me this IP- day of
NOTARY PUBLIC
STATE OF ARIZONA
Maricopa County
My cornmission expires: My Commission ALETA Expires January WILSON 31,2017 j
• 3-1- (seal)
Warrant/Check Number
(if known) (6) 2_9
Original Date of Issue / wP
(if known) (7)
Reason for original issue of Warrant/Check (8):
D Payroll
LI For Services or Goods furnished
'Treasurer's refund/payment tvltA 1-bp Vr, 1xiv-cets Iol
12-ti_ocVecA ID LkV "Ca C 1 ov'",
C: \Users \kgooding\AppData \Local \MicrosoftW.iiThen -low ,NIEt5"es \Content.Outlook\OTSUOPFX \Warrants Chetkr,
Notice of Clairn.doc ELJ
Revised and updated: April 2014 A.R.S. 11-632 & 11-644
SEP 8 2014
MARICOPA COUNTY
CLERK BOARD OF SUPERVIMATS

AFFIDAVIT
FOR WARRANT#330007060
STATE OF ARIZONA
COUNTY OF MARICOPA
Animal Health Service being first sworn, upon oath deposes and says:
That on 10/02/2012 presented to Maricopa County, for payment, Reimbursement from the
Check Enforcement Program. In the Amount of Three Hundred Eighty-Three Dollars and
Ten Cents.
In payment of which the Board of Supervisors caused the Warrant
No. 330007060 to be issued on 10102/2012 drawn on the Expense Fund 767.
Affidavit further says that although he/she was informed and believes that the above
mentioned warrant was regularly issued, the same has never been received, or has been
lost.
WHEREFORE, affiant requests that the Board of Supervisors issue to him/her a
duplicate of said Warrant No. 330007060 in the sum of $383.10
4.
Signed:
Animal biealth Service
)441
Subscribed and sworn to before me this --day of September , 2014
My commission expires: VI( LI Le NOTARY PUBLIC
NICOLE BINNS
Notary Public - Arizona
Maricopa County
My Comm, Expires Nov 11, 2016